1. History

AEDP is a relatively recent addition to the field of psychotherapy dating back to 2000 with its first publication, The Transforming Power of Affect, by Diana Fosha.^[1] AEDP has its origins in intensive short-term dynamic psychotherapy developed by Davanloo and Malan.^[2] AEDP utilizes some methods derived from ISTDP, such as "portrayals" and "the triangle of conflict".^[3]

Ongoing developments in AEDP are derived from the integration of research in the fields of positive affect, change processes, and psychotherapy outcome.^[4][5] as well as clinical and empirical study of AEDP therapist's video-taped sessions.^[6] Video-taping psychotherapy sessions is a standard practice for AEDP psychotherapists.^[7][8]

2. Overview

2.1. Model of Psychotherapy

AEDP proposes a theory and method of how psychotherapy can effect a positive change in a client's overall well-being.^[9] Among the many processes of change utilized by psychotherapies, AEDP privileges emotion processing, which is a series of steps that changes the quality of emotions that a person experiences, with the guidance of an affirming therapeutic relationship.^[10] AEDP is built upon two central premises.^[11] The first premise is that disorders of emotion and relationship are rooted in an early childhood history of traumatic emotional states that are not relieved by a caregiver.^[12] The second premise assumes transformance strivings, that is, that humans are biologically wired to positively respond to healing interventions, and are wired for psychological resilience.^[13] The therapeutic interventions built upon these premises involve identifying and encouraging transformance strivings through therapeutic relationship interventions (such as dyadic affect regulation).^[4] Attachment theory informs AEDP's set of interventions that occur through the therapeutic relationship.^[14]

2.2. Theory of Psychopathology and Healing

AEDP was developed to provide a corrective emotional experience for what, according to AEDP, is considered to be at the root of almost all psychopathology:^[15] that is, an infant/child's experience of prolonged and unendurable emotional/physiological stress, in which recovery could only be possible through the assistance of a soothing caregiver.^[5] It is in the absence of the caregiver and not necessarily the event itself, which may lead to long-term psychological consequences.^[16] Adverse Childhood Experiences studies (ACE)^[17] have demonstrated that early emotional trauma, when untreated or unresolved, can result in the development of attachment disorders,^[18] disorders of emotion regulation (which includes depression and anxiety),^[19] dissociative disorders, affect phobia, and chronic shame.^[20]

AEDP is considered "non-pathologizing" and "healing-oriented" because, similar to person-centered therapy,^[9] AEDP considers symptoms to have developed from the most resourced capacities available to the individual at a given time in their development.^[15]

This approach to positive change by identifying resiliencies extends into a focus upon the positive emotions that arise in response to a corrective emotional experience.^[15] Extrapolating from the research on flourishing,^[21] AEDP includes the identification and amplification of positive emotions toward the self and therapist in order to facilitate neuroplastic change.^[22] The technique developed by AEDP for this purpose is called metatherapeutic processing.^[6]

3. Comparison to Other Contemporary Psychotherapies

1. AEDP concurs with the traditional psychoanalytic premise that individuals develop psychopathological symptoms and defenses to ward off painful feelings.^[23] However, in line with the humanistic psychology tradition, AEDP does not consider the emergence of defense to be a form of pathology, but considers the defense as the only coping mechanism available to the child. Therefore, as opposed to the psychoanalytic focus upon the interpretation of symptoms, AEDP focuses upon identifying and amplifying the client's psychological resilience.^[13]

2. In contrast to intensive short-term dynamic psychotherapy, in which the therapist directly confronts the client's defenses or resistance, the AEDP therapist will explicitly appreciate that the defense was necessary at the time it emerged in the context of the trauma, and will help the client to notice that the defense is no longer necessary.^[24]

3. AEDP and emotion-focused therapy share the treatment goal of healing obstacles to the free expression of emotion. Both consider the healing change to take place in the context of the therapeutic relationship.^[25] In the process of therapeutic work with emotional experience, AEDP systematically applies metaprocessing (the reflection upon the experience as it is happening)^[6] and explores the attachment-based therapeutic relationship as it is unfolding.^[14]

4. Both prolonged exposure therapy (PE) and AEDP are therapies that were developed to treat PTSD. Both therapies aim to reduce trauma-based fears and to promote the recovery of a client's resilience. Among many differences, an essential difference between the two models is the differing views on the etiology of PTSD and therefore the treatment interventions. AEDP views PTSD as developing following a traumatic event when a person is not socially assisted in the repair of the overwhelmed nervous-system and psychological shock. AEDP therefore employs relational strategies (i.e., dyadic affect regulation) to ensure that emotions remain tolerable and will then assist the client in processing the traumatic experiences. PE assumes adequate emotional engagement is necessary, but does not make this engagement a specific focus of intervention.^[26]

4. Core Concepts

4.1. Transformance

Transformance is the term used to describe psychological process underlying healing change.^[25] Transformance refers to each person's innate drive for growth, self-righting, and healing, and to the predictable sequence of an unfolding change process that AEDP aims to activate and facilitate. The term is aligned with the model's emphasis upon a patient's potential and resilience, as opposed to psychopathology.^[16] Transformational experiences are marked by the feeling of vitality, energy and positive affect.^[27]

4.2. Meta-Therapeutic Processing

Meta-therapeutic processing is a cornerstone of AEDP methodology.^[6] The term was created to describe the therapeutic activity of exploring the experience of change as it is happening (transformation), in order to deepen the experience and to facilitate integration and neuroplasticity.^[25] For example, the therapist may ask, "What is it like for you to have had this deep emotional experience right now?"^[28]

Meta-therapeutic processing, which psychiatrist and psychoanalyst James Grotstein recognized as a technical innovation by Diana Fosha,^[23] was later incorporated into focusing-oriented therapy,^[29] a method of psychotherapy originally developed by Eugene Gendlin, whose ideas also influenced Fosha's development of AEDP.^[1]:146,173

4.3. Core Emotion

The overall aim of AEDP is to enable one's emotions to be accessible, vitalized, regulated, and unhindered in expression.^[30] Emotion is a primary source of information about the environment to the self, and about the self to the self, and is also a primary source of communication about the self to others. Clarity of expression of emotions, and a capacity for attunement to another's emotions, is necessary for social well-being and is essential in order to experience one's emotional life as coherent, adaptive and resilient.^[31]

Whether in a moment during a session, or within a larger period of growth, emotion processing is what characterizes an AEDP session.^[32] Empirical studies demonstrate that AEDP's focus on emotions within the therapeutic relationship is associated with client improvement.^[10] Positive affect is a sustained focus of experiential exploration.^[33]

4.4. Core State

Core state is characterized by the natural emergence of well-being, compassion, self-compassion, wisdom, generosity, and clarity that occurs after a successful completion of emotion processing.^[22] Core state is marked by the active creation of a new and coherent life narrative.^[4]

4.5. Dyadic Affect Regulation

Informed by attachment research which describes the role of parent-to-infant affect regulation in the development of secure attachment, the therapist's employs dyadic regulation of affect, through prosody of voice and tracking clients emotion tolerance, to assist the client in remaining within a window of tolerance for emotion processing.^[4]

5. Influences Informing the Model

AEDP integrates insights into how change occurs from the following sources.^[13]

William James observed that inherent in emotion is its power to drive sudden change.^[34] This observation is expanded upon by phenomenological studies of change processes in psychotherapy, and informs the ADEP concept of transformance. They observe that the process of positive change in therapy is not necessarily linear, gradual and protracted, but can also be abrupt and discontinuous, and thereby especially potent.^[35] AEDP therapists track and respond to change processes with attention to the possibility of abrupt change, which can bring about a specific set of emotions called tremulous affects.^[36]

Humanistic psychologists such as Carl Rogers, who posit that individuals possess actualizing tendencies, which AEDP defines as the innate drive toward healing, growth and self-righting. AEDP proposes that this drive can and should be activated from the start of therapy.^[9]

Attachment theory originates in John Bowlby's research which proposes that individuals are biologically driven to form attachment bonds. Attachment theory emphasizes the vital necessity of the formation of a secure attachment relationship between infant and caregiver to ensure the child's successful social, cognitive and emotional development. Attachment theory informs AEDP's emphasis on the importance of co-creating safety and connection in the therapeutic relationship as a prerequisite for subsequent work with difficult emotions.^[37]

Infant research studies the ways in which caregivers and infants interact to provide affective and physiological regulation to the infant. They have found that this interaction creates affect regulating capacities in the developing brain. It is through this affect regulating interaction that secure attachment bonds are formed. The mutually positive affects associated with this dyadic experience is found to be necessary for optimal brain development.^[38] AEDP therapists apply the insights of this research to methods such as dyadic affect regulation and moment-to-moment tracking of emotional changes during a therapy session.

Neuroplasticity research has demonstrated that human beings are wired for growth and tend to actively seek growth promoting opportunities.^[39] Neuroplasticity informs AEDP's concept of transformance, the proposed wired-in motivation of the mind to heal and repair itself.^[40] Metatherapeutic processing is the technique designed to explicitly reinforce (wire-in) positive change as it is occurring.

Affective neuroscience research proposes that individuals possess a neurobiological core self. This core self provides continuity of "sense of self" throughout development and despite change.^[41][42] The development of this core self can become derailed by adverse childhood experiences leading to a range of pathologies in adulthood. AEDP therapists facilitate the development of this core self through its relational interventions leading up to the therapeutic goal of the client's re-creation of a previously fragmented and defeating life narrative into one that is coherent, meaningful, and that includes feelings of pride and agency.^[43]

Emotion theory and research has contributed the understanding of emotions as serving survival purposes and as hard wired into the brain, nervous system, and body. Emotion research has documented the relationship and mental health problems that can result when one's ability to experience and express one's emotions is compromised. AEDP seeks to reconnect the person to emotions that have been blocked, and with therapist guidance, enable these emotions to be fully experienced and processed. When emotions are freely experienced and well tolerated, each core emotion's adaptive action tendency can come online to inform the clients experiences and behaviors.^[30]

Positive psychology's research into broaden-and-build theory of positive emotions^[44] informs AEDP's attention to processing positive emotions in order to promote psychological resilience and flourishing. Broaden-and-build theory informs AEDP's observation that positive emotions emerge with the resolution of difficult emotions. AEDP completes the healing process by systematically metaprocessing positive emotions, with special attention to those that pertain to the therapeutic interaction. This attention to the positive solidifies neuroplastic healing change.^[24]

6. Map of the Transformational Process

The map of the transformational process is a systematic guide developed for the therapist to track where the patient is in the flow of emotion processing. Fosha posits that healing change occurs in progressive stages, called state changes, identifiable to the therapist by a patient's emotional and somatic shifts.^{[12]:254–256} States correspond to the client's progression from emotions that have been defensively blocked from awareness to the visceral experience of the emotions, and finally the integration of emotions. AEDP therapists are trained to identify the signs of state changes, track moment-to-moment shifts within and between each state, and to apply interventions that facilitate movement through four states and three state transformations, described below.^[45]:184 Based on transformational studies, state changes may occur gradually over the course of a session or many sessions, and they may occur suddenly and powerfully.

6.1. State 1: "Co-Establish Safety"

State 1 is characterized by the client's defence mechanisms designed to protect against feeling painful emotions and acceptance of affirmation and care from the therapist (receptive affective capacity). Psycho-education is important during this phase to help the client view symptoms as evidence of resourcefulness (as opposed to pathological) toward self-protection and in the service of the preservation of attachment relationships.^[46] Evidence of the client's resiliency and capacities are highlighted to ensure the client is sufficiently resourced for the work ahead.

Transition from state 1 to state 2: "co-creating safety"

The first state transformation into State 2 is noted by heralding affects, such as a bodily expression of sadness, or indications, such as curiosity, that the client is experiencing relationship security. Heralding affects cue the therapist that the client is ready for exploration of undefended core emotions, within the dyadic regulating therapeutic relationship.^[47]

6.2. State 2: "Experiential Processing and Adaptive Emotional Experience"

State 2 is marked by the client's experience of emotion that were defended against in state 1. The AEDP therapist actively intervenes to ensure that the client's new experience of emotion remains tolerable. A core emotional experience will have a pattern of deepening toward affective/somatic/cognitive integration. As the purpose of core emotion is to prepare for action on behalf of oneself or another, the therapist will assist the client to experience the natural somatic expression of emotion (e.g., feeling the senses, bodily expression and nervous system).^[48] The therapist's regulated nervous system and regulating capacities, through prosody of voice and comfort or encouragement (dyadic regulation of affect), will assist the client in having a safe and well-regulated experience of emotions that were previously felt as unsafe. Clients and therapists report a sense that the therapy is alive and productive when state 2 work is underway.^[49][31]

Transition from state 2 to state 3: "the emergence of resilience"

Positive affects (which do not necessary feel 'good', but feel "right and true"^[1]) mark the completion of the natural wave of the emotion.^[50] Clients may report a sense of relief, lightness, and importantly a vitality, which arises from feeling the energy of the emotion to act in adaptive ways on behalf of oneself. AEDP refers to the affects associated with this state as breakthrough affects. To consolidate the experience and to propel the client toward the next stage of transformational change, the AEDP therapist will metaprocess the completed round of core emotion with the client; i.e., the therapist will ask the client to reflect on what it was it like to just have had the emotional experience, and equally important, will ask the client to reflect on what it was like to do so with the therapist.^[51] Without meta-therapeutic processing, the client simply has an emotional experience that may or may not lead to emotional healing.^[6]

6.3. State 3: "The Metatherapeutic Processing of Transformational Experience"

State 3 is devoted to the metatherapeutic processing of what has just occurred in the progression from states 1 to 2 as well as the transitional states. This metatherapeutic processing evokes its own set of transformational affects and is the focus of State 3.^[52] Transformational affects of State 3 include mastery affects (pride, joy), healing affects (gratitude, feeling moved), the mourning of the self, for one's suffering and for what was lost to oneself in the trauma, and tremulous affects associated with the somatic experience of a change process, especially if it feel sudden.

Transition from state 3 to state 4: "the co-engendering of secure attachment and the positive valuation of the self"

The client feels "calm and ease." The transformational experience feels actualized and the attachment bond between patient and therapist feels solidified.^[49]

6.4. State 4: Core State: "Integration, the Truth Sense"

The AEDP healing sequence is completed with the metatherapeutic processing of the positive emotions that naturally arise following a completion of emotion processing. The result is often a state of clarity and well-being.^[33] Core state is characterized by the client reporting a feeling of calm, vitality, a sense of wellbeing, compassion toward self and others, an expanded perspective, and wisdom.^[53] Core state involves a coherent reorganized self-narrative. The ability to construct a "coherent and cohesive" self-narrative is shown to be highly correlated with secure attachment status in adulthood and with emotional resilience.^[54] The re-organzied self-narrative is evidence to the therapist that a corrective emotional experience has occurred.

7. Critiques

Louis Sass warned that the practice of meta-processing, or deepening the patient's awareness of their experience of the therapeutic interaction as it is happening, could escalate anxiety for clients who have "schizoid" defenses. Sass further referenced William James to support his critique that too much introspection "could be counter-productive, serving less to illuminate something than to rob it of its essence."^[55] Bliming argued metatherapeutic processing could be too "emotionally and experientially direct" for a hostile and defended patient.^[56] In response to Sass's commentary, Fosha clarified that meta-processing occurs when the client is no longer defended and that the activity of meta-processing is "about the experience of experience and experience-near reflection that allows further experience", not "self-awareness" or "self-monitoring".^[57]

Bruce Ecker proposed that memory reconsolidation may be the neurological mechanism underlying healing change in AEDP. He posits that it is the juxtaposition of the client's expectations, based upon negative memories "locked-in" by durable synapses, and the disconfirming present moment experience that re-consolidates memory, leading to neuroplastic change. Ecker suggests that AEDP therapists could enhance the effects of healing change by making this juxtaposition explicit.^[25][40]